Emily Koch
ACNP program
Medicine History and Physical Examination
Chief Complaint: SOB, DOE, cough, chest/back pain
HPI: Mr. M. is a 57 y.o. male with PMH significant for obesity, HTN, and DVT in 2007
who presents to clinic with worsening SOB and DOE over the past 2 months and recently
developed cough, hemoptysis, and chest/back pain with deep inspiration. He is not able to
walk short distances without becoming dyspneic, and patient reports that he was able to
walk 3 miles without SOB 2 months ago. He also reports 1 episode of palpitations and
diaphoresis that occurred 1 week ago and resolved spontaneously when he laid down.
Within the last 3-4 days, the SOB is not always relieved by rest and when he presented to
clinic, he reports that his RA oxygen saturation was 85%. He denies recent air travel, leg
injuries, surgeries, and confirms his usual level of physical activity on most days. His
current employment involves finishing dry wall, which he confirms exposes him to
significant volumes of dust regularly.
PMH: HTN, obesity, perirectal abscess requiring sgy in 2007. DVT, 2007
Code Status: Full
Vaccines: does not have current Pneumococcal or Influenza vaccines
Social History: lives alone, mother recently died, supportive brothers, 70 pack year
smoking history and quit smoking tobacco 2000; denies ETOH abuse current or past
Family History: Father died at 79 of CAD, COPD; Mother died at 79 of esophageal CA,
asthma
Allergies: NKDA
Medications: aspirin 81 mg daily, HCTZ 25 mg daily, lisinopril 20 mg daily
ROS:
Constitutional: Denies fever, chills, night sweats
HEENT: non-contributory
Cardiovascular: Per HPI; difficulty sleeping supine, chronic LLE swelling since DVT
2007
Respiratory: Per HPI; snores
GI: indigestion
GU: non-contributory
Musculoskeletal: weakness over past 2 months
Skin: non-contributory
Neurological: Denies numbness, tingling
Endocrine: non-contributory
Hematologic/Lymphatic: Denies that he bruises easily or bleeds excessively
Psychiatric: non-contributory
Physical Exam: This is a pleasant, obese, well-developed male in mild distress r/t SOB
and pain with deep inspiration.
VS: 36.1, 98. 22. 120/72. 93% O2 sat on 2 L; 6’1” 150.9 kg, BMI 45
HEENT: normal (Head: normocephalic, atraumatic; Neck: supple, FROM, trachea
midline, no carotid bruits, no JVD; Nose: septum midline, moist mucus membranes, no
cough/sputum production during exam)
CV: S1/S2 distant, no murmurs/rubs/gallops/clicks, +2 pulses Bilaterally and
symmetrical throughout, trace LE edema
Lungs: diminished breath sounds with faint upper airway wheeze, shallow but
symmetrical chest expansion, tachypneic, no stridor, no egophony, no fremitus
Abd: normal (soft, nontender, obese, normoactive bowel sounds, no
masses/organomegaly)
MS: exam deferred due to SOB/DOE, no joint tenderness
Lymph: no lymphadenopathy
Neuro: normal (A&O x 4, no focal neuro deficits)
Skin: pink, warm, moist
Psyc: mood is calm, pleasant.
Laboratory & Radiology Review:
Na 137
K 4.1
Cl 98
CO2 26
BUN 22
Creat 1.6, eGFR 49
Glucose 122
WBC 10.25
Hgb 12.6
Hct 38.9
Platelets 160
Ca 8.6
Mg 1.9
Phos 3.9
D-dimer 2510
CTPA: large burden diffuse pulmonary thromboemboli, Right heart strain likely based on
septal bowing, Bilateral lower lobe atelectasis, RV enlarged, 2 mm nodule RML,
coronary artery calcifications are seen.
Echocardiogram: trace mitral regurgitation, EF 60-65%, normal LV function and size,
pulmonary valve and RV not well visualized.
Assessment: This is a 57 y. o. male with PMH DVT treated with 6 months of
anticoagulation, obesity, HTN presenting with SOB, DOE, hemoptysis, and pleuritic
pain. (Before laboratory and radiology review differential diagnoses include pulmonary
embolism, MI, dysrhythmia, new HF, PNA, COPD, flu. I would rule out PE by CTPA,
MI by ECG and troponins, dysrhythmia by continuous telemetry during hospitalization
and CMP, HF by echocardiogram and BNP, PNA/flu by CXR and CBC with differential
and blood cultures, and COPD by PFTs.)
Plan:
1. Massive PE
a. Respiratory support – oxygen to maintain O2 sat >92%, ABGs to evaluate
adequacy of oxygenation and ventilation. Severe hypoxemia or respiratory
distress should prompt intubation and mechanical ventilation. (Patients
with coexistent RV failure may be prone to hypotension after intubation)
b. Monitor hemodynamic status – if hypotensive consider normal saline IV
bolus carefully, start with 500ml if systolic BP drops below 90. IV fluids
can increase RV wall stress and decrease ratio of RV oxygen supply to
demand and result in worsening RV function. If small fluid bolus is not
sufficient for BP support, patient may require vasopressors.
c. Anticoagulation – Heparin continuous infusion 18 units/kg/hour after
initial bolus of 80 units/kg. Check PTT every 6 hours until therapeutic and
then every 24 hours. Adjust Heparin gtt based on hospital nomogram.
Outpatient anticoagulation – enoxaparin 1 mg/kg q 12 hours. Indefinite
Warfarin therapy is indicated for 2 or more episodes of DVT/PE. Start
Warfarin 5 mg daily, check INR in two days, adjust and check 3 days after
each adjustment and then every 2-4 weeks when therapeutic. INR goal is
2-3.
d. Work-up etiology – evaluate for clotting disorders.
i. Get Hematology/Oncology consult. Send labs for Factor V, II
Leiden PCR; dRVVT (lupus anticoag), antiphospholipid antibody
syndrome. Consider malignancy, particularly lung, prostate,
pancreas, stomach, colon, leukemia, Trousseau’s syndrome.
e. Consider risk/benefits of thrombolytic therapy. Hemoptysis most likely
renders patient poor candidate, but discuss with Hematology or
Pulmonology. Thrombolysis may improve RV function and pulmonary
perfusion. (tPA 100 mg over 2 hours.)
f. Consider IVC filter if patient is not a candidate for thrombolysis and/or if
complications to anticoagulation develop.
g. Get Cardiology consult for recommendations on managing RV strain and
preventing cor pulmonale. May need cardiac catheterization. (ECG
findings in PE: Twave inversions V1-V4, sinus tachycardia, S1Q3T3
pattern [the classic signs are a large S wave in lead I, a large Q wave in
lead III and an inverted T wave in lead III], complete/incomplete RBBB)
2. AKI
a. Hold lisinopril, HCTZ, check urine electrolytes, gentle hydration after IV
contrast dye. (eGFR should be >30ml/min in patients receiving contrast
dye and discretion should be used in patients with eGFR <45ml/min.
Following up with extra fluids is highly recommended.)
3. Discharge follow up
a. Patient needs to be seen by outpatient cardiologist for stress test and
possible cardiac catheterization and/or EP study if prolonged palpitations
recur. Consider cardiac event monitor if recurrent palpitations. He could
be experiencing intermittent Afib.
b. Patient should come back as outpatient for sleep study and PFTs to
evaluate for OSA and COPD, respectively.